The Challenging Demographics for the General Physician Dr Phil Rushton Poole Hospital NHS Trust
Mar 30, 2015
The Challenging Demographics for the General Physician
Dr Phil Rushton
Poole Hospital NHS Trust
Literal Approach
• The Demographics• The Challenges• The General Physician?
Old News
Old News
Old News
In the next 20 years • Over-85’s will double
• Over-100’s will quadruple
What’s the problem?
• Currently -Over 65’s account for 60%
Social Care Budget -Twice as NHS-costly
-Hospital spend: Three times as much
Local Picture: Dorset
The Future?
Dorset Christchurch Highcliffe
% aged 0-15 yrs 17.0 15.8 5.6
% aged 15-59 yrs 52.8 48.2 25.3
% aged 60-74 yrs 17.6 20.4 29.8
% aged 75+ yrs 1.7 15.7 39.4
% households ‘pensioner’ 33.4 40.6 70.9
No. ‘economically active’ 178,519 18,859 709
Highcliffe
• Average size practice• c10,000 patients• 6 partners, 3 salaried
HighcliffeHighcliffe Prevalence (%)
National Prevalence (%)
Cancer 4.4 1.7
CHD 7.3 3.4
HF 1.4 0.7
Dementia 1.6 0.5
Stroke 4.1 1.7
HT 23.2 13.6
DM 6.7 5.8
Highcliffe• Particular stresses
Home visitsNHDrug Budget
• And yet:Admission rates lowPrescribing rates low Staff retention good
Meeting the Challenge in Hospital
“Hospitals and medical specialities emerged in an era when many people died in childhood or midlife of single diseases. In 2012, the main activity of general hospitals is the care of (generally older) people with (multiple) long-term conditions.”
The challenge..
• Frailty • Safe Discharges• Readmissions
Comprehensive Geriatric
Assessment
Frailty: Complexity + Poor Reserve
• A state of reduced homeostasis & resistance to stress that leads to increased vulnerability & risk to adverse outcomes such as disease progression, falls, disability & premature death
• Non-specific decompensation: “Acopia”
CGAPain Delirium and Dementia
Depression Nutrition and Hydration
Skin Integrity Sensory Loss
Falls and Mobility ADL’s
Continence Vital Signs
Safeguarding Issues End of Life Care Issues
Safe Discharges: CGA +
• Community services: – IC, GP, DN, LTC, CM
• Care providers: – family, care agency, RH / NH, SW, 3rd Sector
Readmissions
• The new geriatric giant?
Models of Acute Care: Resources
• RCP Acute Care Toolkit 3: Acute medical Care for Frail Older People
• Quality Care for Older People with Urgent and Emergency Care Needs: ‘Silver Book’
• Both support application of CGA within an integrated system.
Local Model: Poole
Problems
• Generic MAU not leading to CGA• LOS > national average• Necessity: Ward closures triggered by
£10m overspend
Aims
• CGA:– Senior clinical review and initiation of
treatment– Early MDT assessment
• Facilitate discharge• Reduce non DME outliers (to close beds
safely)• Manage emergency activity
Ethos of unit• Senior triage of admission calls
– Present alternatives• Early senior assessment
– Medical, Nursing, Therapy• Prioritised diagnostics support• Early Discharge planning • Daily MDTM• Support from SS to keep POC open • Support from IC (Care, Clinical)
Length of stay data
Average LOS DME - April 2010-June 2011
02468
1012141618
April 1
0
May
10
June 1
0
July
10
Aug 1
0
Sep 1
0
Oct
10
Nov
10
Dec
10
Jan 1
1
Feb 1
1
Mar 11
April 1
1
May
11
June 1
1
Jul 1
1
Aug 1
1
Sep 1
1
Oct
11
Month
LO
S (
Day
s)
Occupied bed days
Elderly Admissions, Beddays & Outliers
0
1000
2000
3000
4000
5000
6000
7000
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11
Elderly Beddays Elderly outlier beddays Elderly Admissions (excluding daycase)
Re admissions
Elderly Readmission Rate
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11
7 day readmission rate 30 day readmission rate
Linear (7 day readmission rate) Linear (30 day readmission rate)
Limitations / threats
• Changing relationship with providers• Gaps in service
– Lack of Step-Down beds– Non-commissioned services– Local EMI NH provision
• Ongoing CIP• White Paper…
Summary
• Ageing population• Integrated Systems to deliver CGA,
facilitate safe discharge• Some successes, some Threats
Thanks